Insurance Adjusting and Claims Handling: Roles, Types, and Processes, Exams of Nursing

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Certified Claims Adjuster- Florida Exam Questions with Answers Repair, replacement and recovery of injured lives and damaged property falls to? - Correct answer Insurance Adjusters, CAT Troopers, Field Investigators, Property Appraisers and Front Line Supervisors Insurance Transaction includes: - Correct answer -Solicitation of insurance -Negotiations; -Binding, underwriting and sale of insurance; -Handling or "adjusting" of claims The Role of Insurance is: - Correct answer - Essential Product -Financial Product - Purchase of a Promise -Purchase based on TRUST The different types of insurance are: - Correct answer -Health -Life -Property -Casualty When you buy insurance, you are buying: - Correct answer Peace of Mind Insurance is a Purchase based on: - Correct answer Trust The most important factor in the purchase of insurance is: - Correct answer Trust An assertion of an alleged legal right against a person, entity, company or insurer that carries with it a demand for relief is: - Correct answer Claim Is the same as a request, demand, a letter requesting action, a bill submitted for payment: - Correct answer Assertion Means that the claim may or may not be valid or legitimate, or that there may not be any legal right for belief: - Correct answer Alleged Relief: - Correct answer Compensation or payment. Can also mean: -restitution -return -recovery -replacement Takes form in property or money Third Party Claim: - Correct answer a claim made by a third party against an "insured" person or entity First Party Claim: - Correct answer a claim made by a policy holder against his/her own insurance company for recovery under the policy (contract) for which a premium has been paid Carrier's Claim Handling Goal #1: - Correct answer to help those who have been injured or who have suffered loss for which the insured is responsible or which is covered by the insurance contract Carrier's Claim Handling Goal #2: - Correct answer to minimize loss for the insured party and the carrier. To fairly evaluate the legitimacy and legality of a claim and its value and resolve satisfactory Carrier's Claim Handling Goal #3: - Correct answer -To comply with the requirements of the law or terms of the insurance contract -To pay claims fairly and adequately Carrier's Claim Handling Goal #4: - Correct answer to maintain friendly and satisfactory relations between the injured party, the employer or policy holder, the insurance company and the public Carrier's Claim Handling Goal #5: - Correct answer to satisfy the company's moral and ethical obligation to the public and conduct business (claims) in a friendly, helpful manner An individual who, for compensation, fee or commission, investigates and settles claims arising under property, casualty or surety contracts on behalf of the insurer or the insured: - Correct answer Adjuster The process, or art, of investigating, evaluating, reporting on, negotiating and resolving claims under a policy, or claims against your client, the insurance company or the company for which you work or represent: - Correct answer Adjusting Types of Adjusters: - Correct answer -Staff Adjusters -Independent Adjusters - Public Adjusters Work for Insurance Companies: - Correct answer Staff Adjusters Self Employed or employed by an independent adjusting firm: - Correct answer Independent Adjusters -Liability or Compensability -Damages Adjusters investigate by: - Correct answer -Confirming the loss by verifying bills and statements -Taking detailed statements -Completing scene investigations -Securing photographs or creating diagrams -Canvassing neighborhoods for witnesses -Accident reconstruction -Testing an allegedly defective product Coverage refers to: - Correct answer the insurance contract Define the Doctrine of Proximate Clause: - Correct answer when an initial loss caused by an insured peril that triggers one or more subsequent losses, the peril causing the initial loss is the "proximate cause" of both initial and subsequent losses An insurance company has many goals and standards for claim handling. One of the most important goals of an insurance company is: - Correct answer Help those who have suffered loss for which the insured is legally responsible In the property/casualty industry, a claim is defined as: - Correct answer an assertion of an alleged legal right against a person, entity, company or insurer that carries with it a demand for money as compensation for injuries or damage Which of the following would be considered "work product?" a) An adjuster's claim file notes b) A recorded statement from the claimant c) Written communication between an adjuster and defense counsel. d) An estimate for repairs to damaged property - Correct answer There are many differences between adjusting claims in the healthcare industry and in the property/casualty (i.e. workers' compensation, liability, etc.) industry, one of the fundamental differences is: - Correct answer Which of the following is NOT a defense to a claim of negligence? A.)Breach of Warranty B.)Comparative Negligence C.)Assumption of the Risk D.)No Negligence - Correct answer a.) Breach of Warranty Which of the following is NOT one of the four critical elements of a contract? A.)A mutual understanding and agreement with the terms of the contract. B.)Written evidence of the agreement and its terms. C.)Consideration, consisting of money or a promise of performance. D.)A legal purpose. - Correct answer b.)Written evidence of the agreement and its terms. Which of the following statements is NOT true? A.)A carrier has the right, but not the duty, to settle any claim if it deems reasonable and prudent to do so. B.)Under a liability insurance policy, a carrier's duty to defend is greater than its duty to pay. C.)If a question of coverage arises and cannot be swiftly resolved in favor of the insured, the carrier should immediately tender the claim to its defense attorney and deny the claim. D.)If a lawsuit is filed and served upon an insured, the insured must immediately tender the lawsuit to the insurer or it may jeopardize the carrier's ability to defend the claim, and the insured's rights to coverage under the policy. - Correct answer c.)If a question of coverage arises and cannot be swiftly resolved in favor of the insured, the carrier should immediately tender the claim to its defense attorney and deny the claim. An adjuster has many responsibilities. The adjuster's responsibility as a fiduciary means: A.)Once an adjuster makes a promise, the company is bound by that promise. B.)The adjuster is required to document all activities and continuously report to the company of the progress of claims. C.)The adjuster represents, and controls, the property and financial interests of the client, to whom he/she owes a high degree of loyalty and good faith. D.)The adjuster cannot obligate the insurance company. - Correct answer What is the difference between a peril and a hazard? A.)A peril is a cause of loss, like fire. A hazard is a condition that exists beforehand that increases the likelihood of such a loss, like a messy storeroom or garage that contains lots of toxic chemicals, oily rags, etc. B.)A peril is a hazard gone wrong. C.)When someone drives too fast, that's a peril. When they get into an accident and kill someone, that's a hazard D.)A hazard is a cause of loss and a peril is the condition that created it. - Correct answer a.)A peril is a cause of loss, like fire. A hazard is a condition that exists beforehand that increases the likelihood of such a loss, like a messy storeroom or garage that contains lots of toxic chemicals, oily rags, etc. The primary difference between a staff adjuster and an independent adjuster is: A.)A staff adjuster works for an insurance company and an independent adjuster works independently for themselves or for adjusting firms who represent many clients. B.)A staff adjuster works independently or for adjusting firms who represent many clients and an independent adjuster works for an insurance company. C.)A staff adjuster represents property owners in claims against their own insurance companies and an independent adjuster works independently or for adjusting firms who represent many clients. D.)A staff adjuster works for an insurance company and an independent adjuster represents property owners against their own insurance companies. - Correct answer a.)A staff adjuster works for an insurance company and an independent adjuster works independently for themselves or for adjusting firms who represent many clients. Negligence can best be described as: A.)Liability imposed by jury verdict. B.)Fault that arises from doing something you shouldn't have done, or not doing something you should have done. C.)Liability arising from statutorily imposed liability regardless of fault. D.)Fault imposed on you because you have a greater ability to pay. - Correct answer b.)Fault that arises from doing something you shouldn't have done, or not doing something you should have done. A couple has insured their home for $250,000. A fire ensues and guts their home, resulting in a total loss. An appraisal of the home prior to loss results in a value of $180,000, yet the adjuster is required by law to pay the couple $250,000. This is known as the application of: A.)Actual cash value B.)Payment of policy limits plus a penalty for over-insuring the home. C.)The valued policy law. D.)Replacement cost value - Correct answer c.)The valued policy law. Which of the following is NOT an example of “compensatory damages”? C.)Contacting a witness the day after receiving the claim and getting additional facts about the accident. D.)Sending a letter to a claimant explaining why you can't pay their claim, or offering a compromise based on specific facts and legal issues. - Correct answer b.)Not responding to an insured's calls because you haven't made up your mind yet. Assume that five years ago a couple insured their home for [its then appraised value of] $60,000. Two weeks ago they had a stove fire resulting in an estimated loss of $15,000 for repairs. The adjuster finds that the value of their home is now $100,000, but the home is still only insured for $60,000 and has a deductible of $500. The policy has an 80% coinsurance clause. How much should the adjuster pay to the couple? A.)$15,000 B.)$10,875 C.)$14,500 D.)$11,500 - Correct answer b.)$10,875 The basic and primary functions of an adjuster are: A.)Processing and filing mail. B.)Filing special forms for the insurance company and regulatory bodies. C.)Investigating, managing, evaluating, reporting on, and negotiating and disposing of claims. D.)Making payments and recording claim status claims for property damage, vehicle repairs, damages, medical bills, wage loss and compensation. - Correct answer c.)Investigating, managing, evaluating, reporting on, and negotiating and disposing of claims. After a loss, an Insured has certain responsibilities laid out within the insurance contract. Which of the following is one of the responsibilities of an Insured after a loss? A.)Giving prompt notice of loss to the insurer B.)Reporting the loss to the police C.)Making a record of all damaged property D.)Stopping payment of the most recent premium payment - Correct answer a.)Giving prompt notice of loss to the insurer Florida's Code of Ethics under 69B-220.201(3) begins with an important statement that provides a basis for the very sensitive nature of what an adjuster does. Select that statement from below: A.)It is important for an adjuster to avoid violations of the Unfair Trade Practices Act. The insurer, on whose behalf the adjuster performs, may be subjected to administrative penalties if the adjuster commits an infraction. B.)Any person who is damaged by certain adjuster practices is granted a right to sue the adjuster. C...)Not attempting in good faith to settle claims when it could and should have done so may subject an adjuster to direct liability for bad faith claims practices. D.)The work of adjusting engages the public trust. - Correct answer In a Personal Auto Policy, liability coverage only protects: - Correct answer those individuals meeting the definition of an "insured" under the policy WHEN COVERAGE SYMBOLS #1 OR #21 ARE USED TO DESCRIBE AUTOS FOR WHICH COVERAGE IS PROVIDED UNDER THE BUSINESS AUTO OR GARAGE POLICIES, TO WHICH TYPE OF AUTOS ARE THESE SYMBOLS REFERRING? - Correct answer Any Auto Which of the following symbols is used to provide coverage for "Specifically Described Autos" under a Business Auto Policy? - Correct answer 7 What does symbol "22" next to the Liability, Physical Damage: Comprehensive and Physical Damage: Collision coverage mean? - Correct answer Owned Autos Only